ABSTRACT
The worsening nursing shortage in the United States, coupled with staffing challenges related to the COVID-19 pandemic, has inspired nursing leaders at a 100-bed urban cancer center to develop a Safety Huddle. This patient safety strategy, aimed at improving change of shift communication practices of an 8-bed intensive care unit (ICU) within the cancer center, was implemented at the onset of the COVID-19 pandemic. The Safety Huddle yielded a positive impact on patient care outcomes related to fall prevention. All ICU staff were informed of the priority organizational and unit patient safety goals and collaborated with an all-in mindset and a laser focus on keeping our patients safe. In September 2022, this ICU celebrated two consecutive years of being fall-free. The initial intervention was implemented in April 2020. It began as a checklist of pertinent information that each staff needed to know prior to delivering care for their shift. The Safety Huddle process was reviewed by the lead nurse on the unit and shared with staff nurses, nursing assistants, and unit secretaries at the nurses' station at every change of shift. Each week, the Safety Huddle was updated with the latest information. In January 2021, the Safety Huddle was disseminated to all ICU staff via email in order to facilitate timely communication. During this time, the cancer center transitioned from a hybrid system consisting of paper and minimal electronic charting to an electronic medical record (EMR) effective as of May 2021. The next quarter, starting in September 2021, the ICU recognized 365 days without a fall and posted a celebratory banner at the entrance of the unit to showcase the commendable efforts of the team. The organization's Evidence-Based Practice & Research Council conducted a review of the fall risk assessment tools within the cancer center and at the calendar year close of 2021, adopted the Johns Hopkins Fall Risk Assessment Tool (JHFRAT) that was embedded into the EMR. The Safety Huddle was recently restructured with an addition of a Zero Harm Dashboard, that highlights the number of days since the unit's last significant quality indicator event. To date, the ICU has maintained 730 days without a patient fall. Distributing effective communication and utilizing technology, through a continuous quality improvement framework, has been paramount to our team's success in exceeding such a critical patient safety goal.